Referring to Other Professionals
Assessing Patient Need
"The clinic where I work used to have only physiotherapists working at it but now the owners have decided to hire a chiropractor and a massage therapist. The physiotherapist would do all the initial assessments and then determine which patients should be seen by which professionals. Nothing has been stated explicitly but it seems that the expectation is that the majority of patients will be seen by all three disciplines. The owner would not have hired these individuals to be sitting around doing nothing when they could be bringing in revenue by seeing patients. I am wondering what the College's stand is on two professionals treating the same body part. I am concerned that if we all treat the same body part we would not be able to determine which therapy was helping and which one may have caused harm."There are a few issues in this scenario. The therapist feels pressured to contribute to the financial gain of the clinic. Even though she would not personally gain, as an employee she feels some pressure to comply with the owner's expectations. The therapist is also concerned about her own accountability if there is ever a complaint by a patient. She prefers to be the only treating therapist so that she can avoid possibly being named in a complaint for harm that may have been caused by another.
How should you decide what to do in this situation? Let's consider an extreme example. Your employer has hired someone who fabricates orthotics and insists that you refer all your patients for orthotics regardless of their diagnosis or presentation. You believe that orthotics are very beneficial for some of your patients, but not for all patients. In order to comply with the clinic policy you would have to mislead or even lie to some patients about the so-called benefits of the orthotic and why you are referring. Besides this being a serious breach of the standards of practice of the profession, it also has strong ethical implications.
The ethical principle in the opening scenario and the extreme example are the same. The patient-physiotherapist relationship is a fiduciary (trust) relationship where the patient assumes that his or her physiotherapist is acting in his or her best interest. Physiotherapists are bound by this principle and must make referrals based on a determination of the patient's needs. Referral decisions should never be made according to the therapist or clinic's interests. The therapist should not refer for other services if she thinks they could harm the patient or if she thinks the therapy will be of no benefit.
Conversely, the therapist should not hesitate to refer a patient for a potentially beneficial treatment only because she is worried about her own liability. If it is in the patient's interest to have the same body part treated by more than one professional, then it is the therapist's duty to refer. (For more information, see the Standard for Practice: Concurrent Treatment of a Patient by a Physiotherapist and AnotherHealth Care Practioner.) When patients are presented with treatment choices they should feel confident that the therapist has made these recommendations based on the therapist's opinion of the best available treatment for the patient.
The therapist in the scenario is put in a difficult position because her job may be compromised if she does not refer patients to the other professionals in the clinic. The therapist has to consider her responsibilities to her patients, her own professional integrity and autonomy, and her actions as a representative of the physiotherapy profession.
Considering these issues the therapist should discuss the clinic's referral practices openly with her employer and make it clear that she will base her referral decisions on the best interests of the patients. While she may frequently refer to the other professionals, the criteria for referral will be patient-based.
